Uniting for Ukraine Tuberculosis Screening Experience, San Francisco, California, USA

Ukraine surveillance data suggest high tuberculosis (TB) incidence, including multidrug resistance. Of 299 newcomers from Ukraine screened in San Francisco, California, USA, by using an interferon-γ-release-assay (IGRA) and chest radiograph, 7.4% were IGRA positive and 1 had laboratory-confirmed pansusceptible TB. Screening with IGRA and chest radiograph can help characterize TB risk.

Ukraine surveillance data suggest high tuberculosis (TB) incidence, including multidrug resistance. Of 299 newcomers from Ukraine screened in San Francisco, California, USA, by using an interferon-γ-release-assay (IGRA) and chest radiograph, 7.4% were IGRA positive and 1 had laboratory-confirmed pansusceptible TB. Screening with IGRA and chest radiograph can help characterize TB risk.
One parolee had laboratory confirmation of active TB. The patient reported productive cough and rhinorrhea for 10 days but no other TB symptoms. The patient had no epidemiologic or medical risk factors; HIV test result was negative, IGRA test result was positive, and chest radiograph identified upper lobe nodules. Sputum samples tested showed few AFB smear-positive, NAAT-positive results without rifampin resistance and grew Mycobacterium tuberculosis that was pansusceptible to isoniazid, rifampin, ethambutol, and pyrazinamide. The patient received TB therapy; all household contacts, including a child <5 years of age, tested negative by IGRA at baseline and 8-10 weeks later.

Conclusions
Despite surveillance data reporting high TB incidence (including drug-resistant TB) in Ukraine, only 7.4% of parolees in this investigation received diagnoses of LTBI, and only 1 had laboratory-confirmed, pansusceptible, active pulmonary disease (1)(2)(3). Most parolees were female, possibly reflecting that many men have remained in Ukraine during wartime. All parolees with LTBI were >18 years of age, consistent with reports that TB is uncommon in children from Ukraine (1-3). Most parolees reported no concurrent medical condition, and none tested were HIV positive. The percentages of U4U parolees testing positive by IGRA was low compared with other San Francisco immigrant populations; in the past 5 years, of clients undergoing screening for homeless shelter housing, 20.2% who originated from Mexico and 27.5% from Central America (including Belize, El Salvador, Guatemala, Honduras, and Nicaragua) have tested IGRA positive (San Francisco Department of Public Health, unpub. data).
U4U parolees might not be representative of populations from Ukraine most likely to be given a diagnosis of TB. For example, data for Ukraine for 2021 suggest that HIV, alcohol use, malnutrition, and diabetes are major TB risk factors; those factors were uncommon or absent in the San Francisco U4U population (1-3). Our numbers are reflective of the San Francisco U4U program only and might not be generalizable to other jurisdictions. Nevertheless, vigilance in the U4U population remains warranted because armed conflict and mass displacements have historically been associated with increases in TB incidence, drug-resistant TB, and TB deaths, possibly caused by disruptions in healthcare services, malnutrition, and need for temporary housing with associated crowding and poor hygiene (11  of new refugees before entry into the United States, which include medical history, physical examination, and TB screening (12). For persons originating from countries that have a TB incidence of >20 cases/100,000 persons, the overseas screening requirement for persons >15 years of age includes a chest radiograph (IGRA optional); for those 2-14 years of age, only IGRA is necessary (12). Within 90 days of US arrival, a domestic screening, including history, physical examination, and review of overseas screening results, is recommended; depending on the person, refugees might undergo further evaluation for LTBI (if overseas IGRA was not performed or the result is >6 months old) or active TB (if new symptoms or physical examination abnormalities have developed since overseas screening) (13). In humanitarian situations through which newcomers enter the United States emergently from high-incidence countries without previous overseas evaluation, domestic TB screening with IGRA and chest radiograph (in persons >15 years of age) might be merited to match existing overseas refugee screening recommendations. Because IGRA can show false-negative results for >20% of persons who have active TB, addition of a chest radiograph can help enable rapid and sensitive detection of pulmonary TB, ensure prompt treatment, and prevent local transmission (14). Our inclusion of chest radiographs also provides reassuring data suggesting that infectious pulmonary TB is not being missed in U4U parolees entering San Francisco, despite the high incidence reported in surveillance data for Ukraine.
In late 2022 and early 2023, the Department of Homeland Security implemented programs similar to U4U for new parolees from Venezuela, Nicaragua, Cuba, and Haiti (15). Those parolees have not been screened overseas, have the same TB attestation requirements as U4U, and might have entered the United States under circumstances that convey higher TB risk (e.g., extreme poverty, expolitical prisoners, or long and crowded land journeys) (15). The establishment of U4U screening has enabled SFDPH to assess those populations similarly. To date, of 38 parolees from Venezuela and Nicaragua screened, LTBI has been identified in 3 from Nicaragua; an additional asymptomatic parolee from Nicaragua with a negative IGRA result was given a diagnosis of smear-positive active pulmonary TB. Parolee screening by both IGRA and chest radiograph has provided SFDPH with timely and informative data (including positive and negative results) about TB risk in the diverse parolee populations from high-incidence countries.